The method by which a patient fills a prescription written by his or her doctor has become increasingly complex in the modern health care environment. Most patients with medical insurance must deal with a health care system having four components: an insurer, a physician who is enrolled in the insurer's network, service providers such as pharmacies, hospitals, etc., and the pharmacy benefit manager (PBM)—a management company that manages the pharmacy benefits of the insurer.
The PBM compiles a formulary of medications for the insurer (i.e., a list of medications that the insurer will cover for their enrolled members or that they prefer their members to use for given diagnosis.) In addition, the PBM maintains patient medication histories and other pertinent information related to the safety of the formulary medications for each member. Each PBM is electronically connected to the majority of pharmacies in the nation.
When a prescription is presented at a pharmacy, the pharmacy computer connects to the PBM that manages the pharmacy benefits for that patient. The PBM provides data such as eligibility information, plan details, co-payment requirements and generic options to the inquiring pharmacy. Additionally, the PBM checks to see whether the prescribed medication is within the benefit plan's formulary, and executes a Drug Utilization Review (DUR), which analyzes the prescribed medication versus the patient's known medication and medical history (drug to drug, drug to allergy, drug to medical condition, etc.)
A number of problems can occur during this process if the PBM detects a conflict or potential conflict with the presented script. Formulary variance or contraindication will cause the PMB to signal a notification to the pharmacist. Usually, the pharmacist will make one or more phone calls to the physician to request a change in the prescription in order to make it compliant with the plan, or consistent with the DUR notification. The pharmacist will speak directly to the physician to request any changes being made to the prescription, and any changes are usually entered into the patient's chart. Thus, the current prescription delivery system is increasingly hampered by escalating numbers of necessary phone calls to resolve these prescription-related issues, each of which encroaches on both the pharmacist's and the physician's time.
One attempt to improve the prescription process requires installing custom prescription management software on a local computer within a physician's office, which has the capability of communicating with a remote PBM computer. A physician enters a prescription on a patient's chart, and gives the chart to a staff member (the “user”) who enters the prescription information on one or more data entry screens on the local computer. The software directs the local system to connect with the PBM to determine formulary compliance and to perform a DUR. Any problems with the prescription are conveyed to the user, who must then communicate the difficulty to the physician. The physician alters the prescription, and the user repeats the process until an acceptable prescription is found.
Though this approach does reduce the previously required physician-directed phone calls, it still causes considerable disruption. Each time the system indicates a problem, which may occur several times for a single prescription, the user must leave the computer, find and interrupt the physician, and ask that changes be made. It is primarily for this reason that such a system has not been overwhelmingly adopted.
Such systems also do not provide sufficient means for informing prescribers about medications (new or otherwise) that may be appropriately used by their patients for any given problem when prescribing or about the patient's compliance with past prescriptions. Traditionally, physicians become aware of potential alternative medications in various ways. Drug sponsors often send sales representatives to meet with prescribers or otherwise send literature to inform them about new medications and treatments. However, such methods tend to inundate prescribers with too much information relating to too many different medications such that the volume of information renders the presentation of information for any individual drug ineffective. Moreover, such information may be presented at inopportune times when the prescriber is not prepared to consider the new drug information or simply is unable to schedule a meeting with a particular representative. It may be desirable to have improvements to these systems for informing prescribers of medicines and alternatives thereto in an electronic prescribing environment while avoiding problems that may result from medication conflicts indicated by a DUR and/or the requirements of a patient or plan specific formulary.